[Show abstract][Hide abstract] ABSTRACT: Background :
The U.S. HIV staging system is being revised to more comprehensively track early and acute HIV infection (AHI). We evaluated our ability to identify known cases of AHI using King County (KC) HIV surveillance data.
AHI cases were men who have sex with men (MSM) with negative antibody and positive pooled nucleic acid amplification (NAAT) tests identified through KC testing sites. We used KC surveillance data to calculate inter-test intervals (ITI, time from last negative to first positive test) and the serologic algorithm for recent HIV seroconversion (STARHS). For surveillance data, AHI was defined as an ITI of ≤ 30 days and early infection as an ITI ≤ 180 days or STARHS recent result. Dates of last negative HIV tests were obtained from lab reports in the HIV surveillance system or data collected for HIV Incidence Surveillance.
Between 2005 and 2011, 47 MSM with AHI were identified by pooled NAAT. Of the 47 cases, 36% had ITI < 1 day, 60% had an ITI < 30 days, and 70% (95% CI=55-82%) had an ITI ≤ 6 months and would have been identified as early HIV infection. Of the 47, 38% had STARHS testing and 94% were STARHS recent.
MSM with known AHI were not identified by proposed definitions of AHI and early infection. These known AHI cases were frequently missed by HIV surveillance because concurrent negative antibody tests were not reported. Successful implementation of the revisions to the HIV staging system will require more comprehensive reporting.
The Open AIDS Journal 09/2014; 8(1):45-9. DOI:10.2174/1874613601408010045
[Show abstract][Hide abstract] ABSTRACT: Objectives:To assess the HIV care continuum among HIV-infected persons residing in Seattle and King County, WA, at the end of 2011 and compare estimates of viral suppression derived from different population-based data sources.Methods:We derived estimates for the HIV care continuum using a combination of HIV case and laboratory surveillance data supplemented with individual investigation of cases that seemed to be unlinked to or not retained in HIV care, a jurisdiction-wide population-based retrospective chart review, and local data from the CDC's Medical Monitoring Project and National HIV Behavioral Surveillance.Results:Adjusting for in- and out-migration of persons diagnosed with HIV, laboratory surveillance data supplemented with individual case investigation suggest that 67% of persons diagnosed with HIV and 57% of all HIV-infected persons living in King County at the end of 2011 were virally suppressed (plasma HIV RNA <200 copies/mL). The viral suppression estimates we derived from a population-based chart review and adjusted local Medical Monitoring Project data were similar to the surveillance-derived estimate and identical to each other (59% viral suppression among all HIV-infected persons).Conclusions:The level of viral suppression in King County is more than twice the national estimate and exceeds estimates of control for other major chronic diseases in the United States. Our findings suggest that national care continuum estimates may be substantially too pessimistic and highlight the need to improve HIV surveillance data.
[Show abstract][Hide abstract] ABSTRACT: U.S. guidelines recommend genotyping for persons newly diagnosed with HIV infection to identify transmitted drug resistance mutations associated with decreased susceptibility to NRTIs, NNRTIs, and PIs. To date, testing for integrase strand transfer inhibitor (INSTI) mutations has not been routinely recommended. We aimed to evaluate the prevalence of transmitted INSTI mutations among persons with primary HIV-1 infection in Seattle, WA.
Persons with primary HIV-1 infection have enrolled in an observational cohort at the University of Washington Primary Infection Clinic since 1992. We performed a retrospective analysis of plasma specimens collected prospectively from the 82 antiretroviral-naive subjects who were enrolled from 2007-13, after FDA-approval of the first INSTI. Resistance testing was performed by consensus sequencing.
Specimens for analysis had been obtained a median of 24 (IQR 18-41, range 8-108) days after the estimated date of HIV-1 infection. All subjects were infected with HIV-1 subtype B except for one subject infected with subtype C. Consensus sequencing identified no subjects with major INSTI mutations (T66I, E92Q, G140S, Y143C/H/R, S147G, Q148H/K/R, N155H). Using exact binomial confidence intervals, the upper bound of the 95% CI was 4.4%.
Although our sample size was small, this study does not support the need at this time to evaluate integrase mutations as part of routine consensus sequencing among persons newly diagnosed with HIV-1 infection. However, it is likely that the prevalence of transmitted INSTI mutations may increase with the recent commercial introduction of additional INSTIs and presumably greater INSTI use among persons living with HIV-1.
[Show abstract][Hide abstract] ABSTRACT: Prevention and clinical efforts are increasingly focused on improving the HIV care cascade, the sequential steps from diagnosis to engagement in care and viral suppression. Monitoring of this cascade is largely dependent on HIV laboratory surveillance data. However, little is known about the completeness of these data or the true care status of individuals for whom no data are reported.
We investigated people presumed to be living with HIV/AIDS in King County, WA, who had no laboratory results reported to HIV surveillance for at least 1 year between 2006 and 2010. We determined whether each person had relocated, died, or remained in the county.
Of 7379 HIV-infected people presumed living in King County, 2545 (35%) had 1 or more 12-month gap in laboratory reporting. Among these individuals, 47% had relocated, 7% died, and 38% remained in King County; we were unable to determine the status of 8%. Of individuals remaining in the area, 91% had evidence of returning to or being in HIV care. Case investigations reduced the proportion of individuals thought to be out of care in 2011 from 27% to 16%.
Investigations of individuals without laboratory results reported to HIV surveillance identified large numbers of people who are no longer living in the area. Our findings suggest that current estimates of the HIV care cascade may be too pessimistic and that individual case investigations are required to accurately define the size and composition of the population of people living with HIV in local areas.
[Show abstract][Hide abstract] ABSTRACT: Antiretroviral therapy (ART) is the cornerstone of HIV clinical care and is increasingly recognized as a key component of HIV prevention. However, the benefits of ART can be realized only if HIV-infected persons maintain high levels of adherence.
We present interview data (collected from June 2007 through September 2008) from a national HIV surveillance system in the United States-the Medical Monitoring Project (MMP)-to describe persons taking ART. We used multivariate logistic regression to assess behavioral, sociodemographic, and medication regimen factors associated with three measures that capture different dimensions of nonadherence to ART: dose, schedule, and instruction.
The use of ART among HIV-infected adults in care was high (85%), but adherence to ART was suboptimal and varied across the three measures of nonadherence. Of MMP participants currently taking ART, the following reported nonadherence during the past 48 hours: 13% to dose, 27% to schedule, and 30% to instruction. The determinants of the three measures also varied, although younger age and binge drinking were associated with all aspects of nonadherence.
Our results support the measurement of multiple dimensions of medication-taking behavior in order to avoid overestimating adherence to ART.
The Open AIDS Journal 09/2012; 6:213-23. DOI:10.2174/1874613601206010213
[Show abstract][Hide abstract] ABSTRACT: Background HIV testing remains one of the most effective HIV prevention interventions because most persons newly diagnosed with HIV alter their behaviours to reduce the risk of transmission to others. We examined temporal trends and correlates of the frequency of HIV testing among men who have sex with men (MSM) in King County, WA.
Methods We evaluated electronic medical records of MSM testing for HIV at the Public Health—Seattle & King County (PHSKC) STD Clinic. The intertest interval (ITI) was defined as the number of days between the last reported HIV test and the current visit. ITIs ≤30 days were not considered to be new tests. Correlates of the ITI were determined using Wilcoxon rank-sum tests, Spearman's correlation coefficients, and median regression.
Results Between 1 January 2003 and 7 December 2010, there were 13 637 HIV testing visits among MSM who reported a prior negative HIV test or did not know their status. These men reported a median ITI of 215 days (range: 31–8536; IQR: 124–409); 10 567 (77%) reported an ITI consistent with at least annual testing (<15 months) and 1693 (12%) reported no HIV test in the last 2 years. The median ITI decreased from 229 days in 2003 to 198 days in 2010 (p<0.001). Having sex with men only (vs men and women; p<0.0001), ≥10 male sex partners (p<0.0001), unprotected anal intercourse with a male partner of unknown or positive HIV status (p<0.0001), methamphetamine use (p=0.018), and poppers use (p<0.0001) in the last year were all associated with shorter ITIs, as were decreasing age (p<0.0001) and ever having been diagnosed with syphilis, gonorrhoea, or chlamydial infection (p<0.0001). Race, ethnicity, and injection drug use were not associated with ITI. In multivariate analyses, decreasing age, later visit year, sex with men only, ≥10 male sex partners in the last year, and history of bacterial STI remained associated with shorter ITIs (p<0.001 for all). The median ITI was longer in the 337 men (2.5%) newly diagnosed with HIV compared to those who tested HIV-negative (279 vs 213 days, respectively; p<0.0001).
Conclusions From 2003 to 2010, the median ITI among MSM attending the PHSKC STD Clinic was 215 days, and this has decreased over time. Encouragingly, MSM at highest risk for HIV acquisition have even shorter ITIs, although those newly diagnosed with HIV continue to have longer ITIs. Further efforts are needed to reduce the time that HIV-infected persons are unaware of their status.
[Show abstract][Hide abstract] ABSTRACT: Serologic studies indicate that herpes simplex virus (HSV)-1 and HSV-2 infections are highly prevalent among people infected with HIV. As an ulcerative genital disease, HSV may be important to HIV transmission and HIV-comorbidity. Routine clinical care of HSV in this population has not been described.
Data were abstracted from medical records of HIV-infected individuals by the Adult/Adolescent Spectrum of HIV Disease Project. Clinician-documented HSV diagnosis and HSV treatment, defined as any prescription for acyclovir, valacyclovir, or famciclovir, were the outcomes of interest. We present descriptive statistics and trends in HSV diagnosis and treatment.
Between 1989 and 2004, 61,299 people were followed in this study. HSV was diagnosed in 20% of the population, and 32% of the population received HSV antiviral prescriptions. Prescriptions for episodic treatment were given to 28% of patients, and 11% received prescriptions for suppressive therapy. The average annual rate of HSV diagnosis declined by 31% during the course of the study.
Clinically recognized HSV infections were frequent despite declining rates of diagnosis. Providers should have a high index of suspicion for HSV and consider routine screening and suppressive therapy for patients at risk of clinical disease.
[Show abstract][Hide abstract] ABSTRACT: To compare population-based metrics for assessing progress toward the US National HIV/AIDS Strategy (NHAS) goals.
Analysis of surveillance data from persons living with HIV/AIDS (PLWHA) in King County, Washington, USA, 2005-2009.
We examined indicators of the timing of HIV diagnosis [intertest interval, CD4 cell count at diagnosis, and AIDS ≤ 1 year of diagnosis (late diagnosis)]; linkage to initial care (CD4 or viral load report ≤3 months after diagnosis) and sustained care (a laboratory report 3-9 months after linkage); engagement in continuous care in 2009 (at least two laboratory reports ≥3 months apart); and virologic suppression.
Thirty-two percent of persons had late HIV diagnoses, 31% of whom reported testing HIV negative in the 2 years preceding their HIV diagnoses. Linkage to sustained care, but not linkage to initial care, was significantly associated with subsequent virologic suppression. Among 6070 PLWHA in King County, 65% of those with at least one viral load reported in 2009 and 53% of all PLWHA had virologic suppression. Although only 66% of all PLWHA were engaged in continuous care, 81% were defined as engaged using the denominator proposed in the NHAS (at least one laboratory result reported in 2009 excluding persons establishing care in the second half of the year).
Proposed metrics for monitoring the HIV care continuum may not accurately measure late diagnoses or linkage to sustained care and are sensitive to assumptions about the size of the population of PLWHA. Monitoring progress toward achievement of NHAS goals will require improvements in HIV surveillance data and refinement of care metrics.
AIDS (London, England) 01/2012; 26(1):77-86. DOI:10.1097/QAD.0b013e32834dcee9 · 6.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To examine trends in and correlates of liver disease and viral hepatitis in an human immunodeficiency virus (HIV)-infected cohort.
The multi-site adult/adolescent spectrum of HIV-related diseases (ASD) followed 29 490 HIV-infected individuals receiving medical care in 11 U.S. metropolitan areas for an average of 2.4 years, and a total of 69 487 person-years, between 1998 and 2004. ASD collected data on the presentation, treatment, and outcomes of HIV, including liver disease, hepatitis screening, and hepatitis diagnoses.
Incident liver disease, chronic hepatitis B virus (HBV), and hepatitis C virus (HCV) were diagnosed in 0.9, 1.8, and 4.7 per 100 person-years. HBV and HCV screening increased from fewer than 20% to over 60% during this period of observation (P < 0.001). Deaths occurred in 57% of those diagnosed with liver disease relative to 15% overall (P < 0.001). Overall 10% of deaths occurred among individuals with a diagnosis of liver disease. Despite care guidelines promoting screening and vaccination for HBV and screening for HCV, screening and vaccination were not universally conducted or, if conducted, not documented.
Due to high rates of incident liver disease, viral hepatitis screening, vaccination, and treatment among HIV-infected individuals should be a priority.
World Journal of Gastroenterology 04/2011; 17(14):1807-16. DOI:10.3748/wjg.v17.i14.1807 · 2.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine if anonymous and confidential testers differ in recency of human immunodeficiency virus (HIV) infection at time of testing and prevalence of antiretroviral drug (ARV) resistance. We examined data from the Centers for Disease Control and Prevention-sponsored Antiretroviral Drug Resistance Testing project, which performed genotypic testing on leftover HIV diagnostic serum specimens of confidentially and anonymously tested ARV-naïve persons newly diagnosed with HIV in Colorado (n = 365 at 11 sites) and King County, Washington (n = 492 at 44 sites). The serologic testing algorithm for recent HIV seroconversion was used to classify people as likely to have been recently infected or not. Type of testing, anonymous or confidential, was not significantly associated with either timing of HIV testing by serologic testing algorithm for recent HIV seroconversion or resistance rates. Mutations conferring any level of ARV resistance were present in 17% of testers, and high-level resistance mutations were present in 10%. Anonymous testers were significantly more likely to have CD4+ counts >500 cells per mm(3) (45% vs. 28%; p = 0.018), indicative of an early infection. This study indicates that anonymous testers have demographic differences relative to confidential HIV testers but were not more likely to exhibit drug resistance. Findings related to when in the course of disease anonymous testers are tested are inconsistent, but anonymous testers had higher CD4 counts, which indicates early testing and is consistent with other studies.
[Show abstract][Hide abstract] ABSTRACT: Human immunodeficiency virus (HIV)-infected individuals are at increased risk for primary lung cancer (LC). We wished to compare the clinicopathologic features and treatment outcome of HIV-LC patients with HIV-indeterminate LC patients. We also sought to compare behavioral characteristics and immunologic features of HIV-LC patients with HIV-positive patients without LC.
A database of 75 HIV-positive patients with primary LC in the HAART era was established from an international collaboration. These cases were drawn from the archives of contributing physicians who subspecialize in HIV malignancies. Patient characteristics were compared with registry data from the Surveillance Epidemiology and End Results program (SEER; n = 169,091 participants) and with HIV-positive individuals without LC from the Adult and Adolescent Spectrum of HIV-related Diseases project (ASD; n = 36,569 participants).
The median age at HIV-related LC diagnosis was 50 years compared with 68 years for SEER participants (P < .001). HIV-LC patients, like their SEER counterparts, most frequently presented with stage IIIB/IV cancers (77% vs. 70%), usually with adenocarcinoma (46% vs. 47%) or squamous carcinoma (35% vs. 25%) histologies. HIV-LC patients and ASD participants had comparable median nadir CD4+ cell counts (138 cells/µL vs. 160 cells/µL). At LC diagnosis, their median CD4+ count was 340 cells/µL and 86% were receiving HAART. Sixty-three HIV-LC patients (84%) received cancer-specific treatments, but chemotherapy-associated toxicity was substantial. The median survival for both HIV-LC patients and SEER participants with stage IIIB/IV was 9 months.
Most HIV-positive patients were receiving HAART and had substantial improvement in CD4+ cell count at time of LC diagnosis. They were able to receive LC treatments; their tumor types and overall survival were similar to SEER LC participants. However, HIV-LC patients were diagnosed with LC at a younger age than their HIV-indeterminate counterparts. Future research should explore how screening, diagnostic and treatment strategies directed toward the general population may apply to HIV-positive patients at risk for LC.
Clinical Lung Cancer 11/2010; 11(6):396-404. DOI:10.3816/CLC.2010.n.051 · 3.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: HIV-infected individuals with access to highly active antiretroviral therapy (HAART) are living longer and the causes of excess morbidity and mortality among people living with HIV/AIDS (PLWHA) are becoming comparable to individuals without HIV infection. However, many PLWHA smoke cigarettes-a well known contributor to excess morbidity and mortality. To investigate the association between smoking and mortality among PLWHA during the HAART era (1996+), we conducted a retrospective cohort study of 2,108 PLWHA enrolled in Seattle and King County's Adult and Adolescent Spectrum of HIV Disease Study. Adjusted hazard ratios (aHRs) for all-cause and cause-specific mortality were obtained using Cox proportional hazards regression. Compared to never smokers, current smokers (aHR = 1.8, 95% CI: 1.3, 2.3) and individuals with an increased dose and/or duration of smoking were at greater risk of all-cause mortality. Although additional research is needed to evaluate the full effect of smoking on cause-specific mortality, smoking cessation programs should target PLWHA to further increase their life expectancy.
AIDS and Behavior 03/2010; 15(1):243-51. DOI:10.1007/s10461-010-9682-3 · 3.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Nephropathy complicates the course and adversely impacts on the prognosis of HIV-infected patients. We examined trends and correlates of all-cause nephropathy (ACN).
Correlates of and trends in ACN were examined in the entire Adult/Adolescent Spectrum of HIV Disease longitudinal observational cohort. Patients were enrolled and followed in the cohort for a median period of 3 years between January 1990 and December 2003 in 11 US metropolitan areas.
The incidence of ACN rose among HIV-infected individuals through the mid-1990s, then declined. The proportion of patients with ACN at the time of death increased over the study period. Black race, injection-drug use (IDU), indinavir, hypertension, diabetes, decreased CD4+ lymphocyte count, increased viral load, and increased age were all highly associated with ACN.
Nephropathy represents an important health disparity impacting HIV-infected blacks and IDU with implications for mortality.
Journal of the National Medical Association 12/2009; 101(12):1205-13. · 0.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the characteristics of human immunodeficiency virus (HIV)-infected black African immigrants living in King County, Washington, we evaluated delay in HIV diagnosis, access to HIV care, and risk of progression to AIDS or death.
We compared differences in the risk of progression to AIDS or death between HIV-positive African-born black individuals and 2 groups of HIV-positive US-born individuals.
There were significant differences across the groups in residence at time of HIV diagnosis, gender, HIV transmission category, and initial CD4 count. Black Africans were more likely to present with an AIDS diagnosis (45%), compared to both US-born nonblacks (25%) and US-born blacks (35%). No significant independent associations were observed in rates of HIV disease progression when black African immigrants were compared to their US-born counterparts.
Once having initiated HIV care, African-born blacks accessed HIV care and progressed to AIDS at similar rates compared to US-born individuals. However, African-born blacks initiated care with more advanced HIV disease. Results underscore the need for health interventions promoting HIV testing among black African immigrants and reducing barriers to HIV testing.
Journal of the National Medical Association 12/2009; 101(12):1230-6. · 0.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: HIV-infected individuals are at an increased risk for developing primary lung cancer.
Objective: To review and compare the clinicopathological characteristics and treatment outcomes of HIV-LC patients with those of primary LC patients who are HIV negative. A secondary objective is to compare demographic and immunologic parameters of HIV-LC patients with an HIV+ population without LC.
Methods: A retrospective study of 77 HIV+ patients with primary LC in the HAART era. Demographic and clinical data were compared with primary LC statistics from registries linked to the US NCI's Surveillance Epidemiology and End Results (SEER) and with HIV+ individuals without LC from the Adult and Adolescent Spectrum of HIV-related Diseases (ASD) Project.
Results: The median age at HIV-LC diagnosis was 50 years compared to the median 68 years for SEER participants (p < 0.001). HIV-LC patients, like their SEER counterparts, most frequently presented with stage III (29% vs. 26%) and stage IV (55% vs. 40%) cancer, and more often with adenocarcinoma (42% vs. 37%) than squamous cell carcinoma (32% vs. 21%). The median nadir CD4+ cell count of HIV-LC and ASD participants (133 cells/μL vs. 158 cells/μL) were comparable, but the former group smoked more cigarettes than the latter group (mean, 40 vs. 15 pk/yrs). At the time of HIV-LC diagnosis, 64 (83%) patients were receiving HAART, 45 (65%) had a non-detectable HIV viral load, and the median CD4+ count was 325 cells/μL. Of the 41 (53%) HIV+ patients who received chemotherapy the response rate was 42% (15% CR, 27% PR). Median survival of HIV-LC patients and SEER participants was 9 months.
Conclusion: HIV-LC patients had comparable nadir CD4+ cell counts to ASD participants. Apart from smoking habits, both groups had similar demographic and behavioral characteristics. The distribution of tumor histologic type and overall survival was similar to SEER participants. At the time of LC diagnosis, HIV+ patients were most likely to be on HAART, with well-controlled HIV viremia, and significant immune reconstitution.
Infectious Diseases Society of America 2009 Annual Meeting; 10/2009
[Show abstract][Hide abstract] ABSTRACT: HIV-1 drug resistance has been detected in 8%-24% of recently infected North Americans when assessed by consensus sequencing of plasma. We hypothesized that rates were likely higher but not detected because drug-resistant mutants are transmitted or regressed to levels below the limit of detection by consensus sequencing of HIV-1 RNA.
Specimens from antiretroviral-naive individuals recently diagnosed with HIV-1 infection were compared at 15 codons to determine if testing of DNA using a sensitive oligonucleotide ligation assay (OLA) would detect drug resistance mutants not evident by consensus sequencing of serum.
HIV-1 drug resistance at 15 major resistance codons was greater by OLA compared with consensus sequencing: 18 of 104 vs. 12 of 104 individuals (P < or = 0.008) and 33 vs. 18 total mutations (P < or = 0.001); increasing the rate of detection at these 15 codons by 83%. Additional mutations were detected by consensus sequencing at L33, M46, D67, V108, and K219 that were not assessed by OLA.
The increased detection of drug-resistant HIV-1 by testing peripheral blood cells with a sensitive assay implies that both low and high levels of drug-resistant mutants are transmitted or persist in antiretroviral-naive individuals, suggesting that the clinical relevance of mutants persisting at both levels should be evaluated.